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A 34-year-old gentleman, who had undergone orthotopic liver transplantation (OLT) for idiopathic fulminant hepatic failure in November 2004, presented with jaundice andabnormal liver function tests. Magnetic resonance imaging (MRI) identified an anastomotic biliary stricture with dilated intrahepatic ducts, which were also confirmed at endoscopic retrograde cholangiopancreatography (●" Fig.1). Although a 0.035-inch hydrophilic guidewire (Acrobat; Cook Medical, WinstonSalem, NC, USA) was passed through the anastomosis, the stricture was not negotiable with standard dilation catheters or with a Soehendra tapered 4F dilator (SBDC-6; Cook Medical) (●" Fig.2). As a last resort, “brush recanalization” with an RX-wire-guided cytology brush (Boston Scientific Corp., Natick, MA, USA) was used to treat the stricture. Under endoscopic and fluoroscopic control, the duodenoscope was gently advanced into the duodenum in order to straighten the common bile duct and allow us to orient the brush movements precisely in the direction of the stricture. Surprisingly, the brush advanced successfully through the stricture, possibly due to the stiffness of the brush catheter (●" Fig.3). The 8F brush catheter was then pushed through the stricture, resulting in further dilation. Finally an 8cm long, 10mm Niti-S biliary, fully covered, self-expandable metal stent (Taewoong Medical Co. Ltd., Seoul, South Korea) was placed across the stricture to Fig.1 Magnetic resonance image of the anastomotic stricture in a 34-year-old man who had undergone orthotopic liver transplantation.

“Brush recanalization” of a challenging biliary stricture after liver transplantation: a novel application for an old device